Diagnosis of Dysmenorrhea
Dysmenorrhea is diagnosed clinically based on the characteristic history of cramping lower abdominal pain occurring just before or during menstruation, accompanied by a normal physical examination. 1, 2, 3
Primary vs. Secondary Dysmenorrhea
Primary Dysmenorrhea
Primary dysmenorrhea is defined as painful menses with cramping in the lower abdomen occurring just before or during menstruation in women with normal pelvic anatomy and a normal physical examination. 1, 2, 3
Key diagnostic features include:
- Cramping pain in lower abdomen/pelvis starting just before or during menses 1, 2
- Pain typically lasting 1-3 days 2
- Associated symptoms may include sweating, headache, nausea, vomiting, diarrhea, tremulousness 1
- Normal physical examination (including pelvic exam if sexually active) 4
- No underlying pelvic pathology 1, 3
Secondary Dysmenorrhea
Secondary dysmenorrhea presents with similar pain patterns but results from underlying pelvic pathology such as endometriosis or uterine fibroids. 2, 5
Red flags suggesting secondary dysmenorrhea requiring further investigation:
- Abnormal uterine bleeding 4
- Dyspareunia (painful intercourse) 4
- Noncyclic pelvic pain 4
- Changes in intensity and duration of pain over time 4
- Abnormal pelvic examination findings 4
- Pain persisting despite NSAIDs and/or oral contraceptive use 1
Diagnostic Workup
Clinical History
Essential history elements include:
- Timing of pain relative to menstrual cycle 1, 2
- Duration and severity of pain 1, 2
- Associated symptoms (nausea, vomiting, headache, diarrhea) 1, 2
- Impact on daily activities, school, or work attendance 1
- Age at menarche, menstrual cycle length, menstrual flow volume 1
- Sexual history 4
- Family history of dysmenorrhea 1
- Current contraceptive use 1
- Response to previous treatments 1
Physical Examination
A pelvic examination should be performed in patients who have had vaginal intercourse to identify any pelvic pathology. 4 The physical examination in primary dysmenorrhea should be completely normal. 1, 3, 4
Additional Testing
For suspected secondary dysmenorrhea:
- Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected based on history or abnormal physical findings 4
- Pregnancy test to rule out pregnancy-related causes 2
- STI screening if sexually active 2
No routine laboratory or imaging studies are required for primary dysmenorrhea with a normal history and physical examination. 3, 4
Common Diagnostic Pitfalls
Do not assume all menstrual pain is benign primary dysmenorrhea. Persistence of severe dysmenorrhea despite NSAIDs and oral contraceptive use is a strong indicator of organic pelvic disease, particularly endometriosis, and mandates referral to gynecology for laparoscopic evaluation. 1
In adolescents, do not overlook endometriosis as a cause of secondary dysmenorrhea, which warrants prompt gynecology referral. 2 Endometriosis is the most common cause of secondary dysmenorrhea. 4
The diagnosis is primarily clinical and does not require extensive testing in the absence of concerning features. 2, 3 The key is distinguishing primary from secondary dysmenorrhea through careful history and physical examination, as this determines appropriate management and the need for further investigation.